SOCCER CENTERS of EXCELLENCE
@ the University of VIRGINIA
Charlottesville, VA
June 28th – July 1st, 2015
APPLICATION
Name_________________________________________________________________
Address________________________________________________________________
City_________________________________________State_______Zip____________
Age_______Date of Birth _____/_____/_____HS Grad Yr.________Grade Fall 2015_________
Parent_________________________________________________________________________
Phone (H)___________________________________ (C)_______________________________
Parent Email (please print carefully) ________________________________________________
Roommate_____________________________________________________________________
Additional Roommate requests_____________________________________________________
Player Position (circle one)
Forward
Midfield Defender Goalkeeper
***All players will receive 2 Virginia Soccer camp T-shirts and a soccer ball***
Fee $585.00
Person Making Payment_____________________________ Relationship to Camper_____________________
____ $125 Non-Refundable Deposit – ($460 Balance due June 1)
____ $585 Payment in Full
I am attending camp with a group. We are submitting all twelve (12) applications together in order to receive
the $25 discount.
Name of Team/Group____________________________________________________________
Contact Person______________________________________ Phone______________________
Please make checks payable and mail to:
Soccer Centers of Excellence
c/o Virginia Women’s Soccer
PO Box 400847
Charlottesville, VA 22904
Enrollment can only be secured by returning an application, medical form, and a deposit of $125. The deposit is
non-refundable and will be applied to the total fee. The balance is due June 1, 2015. The camp is owned and
operated by the Soccer Centers of Excellence, LLC.
Participant’s Name__________________________________
SOCCER CENTERS OF EXCELLENCE AGREEMENT
Soccer Centers of Excellence LLC is owned and operated by Head Coach Steve Swanson, and it may be held at the
University of Virginia and use some of the University's facilities. However, Soccer Centers of Excellence is not owned or
operated by the University, and the Head Coach and Coach's assistants are not employees or agents of the University in
their operating of the camp.
Please read the following agreement carefully before signing. Although camp participation is encouraged, it is encouraged
only if health and safety are considered.
CERTIFICATION OF PHYSICAL FITNESS TO PARTICIPATE:
1. I understand that a risk of participating in any sport, including Soccer Centers of Excellence, is the risk of injury,
including but not limited to serious permanent injury, paralysis, and death. To minimize the risk of injury, I agree to tell
my child to obey all safety rules and to report fully any problems related to his/her physical condition to the summer camp
coaches or assistants as soon as the problem begins.
2. By signing below, I certify the following:
--That my child is not currently under the care of a physician for an injury or illness that would prevent his/her safe
participation in the summer camp;
--That my child is not currently being treated for or recovering from an orthopedic injury that would prevent his or
her safe participation in the summer camp;
--That my child has no history of fainting or other problems related to strenuous exercise; and
--That my child is in good health and there is no reason he or she cannot safely participate in strenuous physical
activity.
Parent/Guardian Signature________________________
Date: __________
CONSENTS:
1. By my signature below, I hereby give permission for Soccer Centers of Excellence and its employees and agents to
obtain medical treatment for my child, ________, in the event of accident or illness during his/her presence at the camp.
2. By my signature below, I hereby give consent to have my child be photographed or video- or audio-taped during camp
activities, and I agree that the images so obtained may be used for educational and public relations purposes by Soccer
Centers of Excellence.
Parent/Guardian Signature________________________
Date: __________
RELEASE:
1. In consideration for accepting my child into Soccer Centers of Excellence, which uses University facilities, I do hereby
agree that I am and shall be responsible for all costs associated with any injury or loss that may be sustained by my child as
a result of his or her participation at the camp. I also certify that I have health insurance that provides adequate coverage
for injuries or illness my child may sustain while participating in Soccer Centers of Excellence.
2. By my signature below, I also agree to release and promise not to sue the Commonwealth of Virginia, the University of
Virginia, or their employees or agents, for any damages, loss, injury, or death arising from my child's participation in
Soccer Centers of Excellence, unless such damages, loss, injury, or death are caused by willful and wanton conduct of such
employees or agents.
Parent/Guardian Signature________________________
Date: __________
Athletic Camp/Clinic Sports Medicine Information Sheet
Please provide the following medical information for your child:
Child’s Name
Primary emergency contact (Name, relationship, phone number)
Name
Relationship
Phone Number
Secondary emergency contact (Name, relationship, phone number)
Name
Relationship
Phone Number
Allergies (medication, food, bee sting, poison ivy, etc.)
Please describe the nature of the reaction (rash, hives, difficulty breathing, etc.)
Injury history (e.g. recent sprains, fractures):
Medical conditions (e.g. asthma, diabetes, cardiac disorders, seizure disorders)
Medications currently taking
Date of last tetanus shot (month/year)
Participant’s Name______________________________
INSURANCE CARD (copies of front & back)